• Incident type

  • Location Statement Recorded
  • Interview Conducted On

  • Statement Prepared By

  • Merit number

  • Name of Witness

  • Address
  • Phone number

  • Mobile phone number

  • Date of Birth

  • Statement

I hereby acknowledge that this statement is true and correct and I make it in the belief that a person making a false statement in the circumstances is liable to the penalties of perjury.

  • Witness

Acknowledgement made and signature witnessed by me

  • Shire Officer

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.